American College of Physicians: Internal Medicine — Doctors for Adults ®

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Strategies for coping with the flu vaccine shortage

Health officials say some vaccine may still arrive in time to help with the worst of the flu season

From the November ACP Observer, copyright 2004 by the American College of Physicians.

By Janet Colwell

Last month's announcement, that almost half the nation's flu vaccine supply would not be distributed, hit physicians' offices just as they were setting up flu clinics and contacting high-risk patients to come in to be immunized. Physicians who had some vaccine were inundated with panicked patients, while others were facing a flu season without any vaccine at all, amid widespread reports of rampant price gouging by unscrupulous distributors.

But at press time, officials from the Centers for Disease Control and Prevention (CDC) were indicating that the shortage might not be as dire as first predicted, if physicians act quickly. The CDC is working with the country's other major manufacturer of injectable flu vaccine to carefully dole out unshipped supplies. Doctors who place orders now may be able to line up some vaccine later this fall or early winter.

The CDC has also issued antiviral medication guidelines to help curtail outbreaks among patients who can't get vaccinated. By rationing vaccine supplies and pushing prudent use of antivirals and preventive measures, public health officials are hoping physicians will be able to stave off the season's most serious complications.

Tough choices

Since Chiron Corporation announced last month that it would not deliver almost 50 million vaccine doses, the nation's remaining injectable vaccine manufacturer, Aventis Pasteur, has been working with the CDC to ship out its remaining 22.4 million doses at a rate of 2 million to 3 million doses per week. The company had already shipped 33 million doses before Chiron 's product was quarantined. (At press time, Aventis announced that an additional 2.6 additional doses would be available in January.) Physicians who have already received some vaccine supplies find themselves making some tough decisions: Given the high demand for vaccine and the number of high-risk patients, who should they immunize?

"The high risk groups are based on science," said Kathleen M. Neuzil, FACP, a Seattle internist and ACP's liaison to the CDC's influenza working group. "We know that babies, seniors and patients with chronic conditions are more likely to be hospitalized from the flu than healthy young adults." But this season's shortage, she added, is forcing physicians to sub-prioritize among high-risk individuals.

"There are no studies to tell us if a 70-year-old healthy person is at higher risk than a 59-year-old with severe diabetes," she said. She said she finds the hardest patients to refuse are healthy adults living with an at-risk family member, such as a patient with an immunosuppressive disease. Dr. Neuzil said she has been advising these family members to get FluMist, the nasal spray vaccine.

Unfortunately, doctors must rely on healthy patients not to ask for the vaccine. (See "Talking to healthy patients about flu shot alternatives.") At press time, eight states and the District of Columbia had issued emergency orders directing providers to not vaccinate anyone not identified by the CDC as high risk. Failure to comply with those orders could lead, in some jurisdictions, to fines of up to $1,000 or to six months imprisonment.

A waiting game

In phase one of the vaccine redistribution plan of unshipped doses, the CDC and Aventis are carefully targeting high-risk patients, shipping 14.2 million doses of vaccine over a six-week period to Veterans Administration facilities; nursing homes and acute care hospitals; the CDC's Vaccines for Children program recipients; and pediatricians—all of whom were to receive 100% of their requested doses. Private sector Aventis customers, as well as state and local public health departments, were expected to receive up to 50% of their initial orders, based on needs.

In phase two of the plan, which may take place simultaneously, the CDC and Aventis will ship another 8.2 million doses to Chiron customers, including public health departments, long-term and acute-care facilities, pediatricians, obstetrician/gynecologists, internists, general practitioners and family physicians.

Physicians who ordered from Chiron should contact their public health departments and stress that they serve a high-risk patient population, particularly for practices with a large number of geriatric patients. The CDC also plans to hold back some shipments to send to areas of the country that suffer severe outbreaks.

The good news is that "there may be some vaccine deliveries into November, even after Thanksgiving," said William Schaffner, MACP, an infectious disease specialist at Nashville's Vanderbilt University Hospital, who serves on the CDC's Advisory Committee for Immunization Practices (ACIP) as well as on ACP's Adult Immunization Initiative.

Those shipments may help curtail severe complications, particularly if the flu season peaks late. "If we have a flu season that starts in January and peaks in February," said Dr. Neuzil, "we can give vaccine through December and into January, and still do some good."

Physicians should notify their local health departments about their vaccine needs for high-risk patients, in case local authorities have supplies to redistribute. (In an Oct. 26 letter to the CDC, ACP recommended that local public health departments develop plans to distribute remaining local supplies to community providers.)

Physicians caring for healthy patients aged 5-49, particularly those who are health care workers or contacts of high-risk patients, could order FluMist.

FluMist's manufacturer, MedImmune Inc., has announced that about 3 million doses of the spray will be available this year. Physicians can order FluMist directly by calling MedImmune at 800-949-3789 or online. The company is limiting orders to 70 doses per practice.

New strategies

The CDC has also released new interim guidelines on the use of antivirals for prophylaxis and treatment. As with flu vaccine, high-risk patients should be given priority for antivirals. Guideline highlights include:

  • Using amantadine or rimantadine for prophylaxis. Rimantadine is not approved for children under age 13.

  • Using oseltamivir or zanamivir for treatment, as supplies allow.

In addition, the guidelines recommend that people who live or work in institutions that care for high-risk patients, including nursing homes and hospitals, should be given antivirals in the event of an outbreak. Antiviral prophylaxis is also recommended for high-risk patients and for health care workers who can't get vaccinated, and for patients with immunosuppressive conditions.

Internists should also focus on patient education and prevention, Dr. Schaffner said. The vaccine shortage makes it even more important to get out common sense advice about washing hands frequently and avoiding people with respiratory symptoms. Many public health offices are a good source for educational hand-outs and brochures on who should get a flu shot and tips on preventing the spread of infection.

And because pneumonia is a common complication, Dr. Schaffner added, now is a great time for patients to have pneumococcal vaccinations.

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Where to find more information

  • Centers for Disease Control and Prevention. Up-to-date news about the shortage and what the government is doing.

    Recent additions to the CDC site include:

    • A signup page to receive e-mail updates on the flu vaccine shortage and other emergency events.

    • Links to state and local health departments.

    • Printable, downloadable patient education flyers on who should get flu shots and ways to prevent the flu.

    And many states are using the CDC's Health Alert Network (HAN) to communicate with providers. Physicians can access their state HAN by clicking on the CDC map.

  • National Association of County and City Health Officials. Information on vaccine supply and distribution; interim recommendations; news updates; and public health resources.

  • The Association of State and Territorial Health Officials. News, recommendations and information on what states are doing to get vaccine, educate the public and implement guidelines.

  • National Association of Attorneys General. Click on the link for your state to report price gouging.

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Getting reimbursed for immunizations

The Centers for Medicare and Medicaid Services (CMS) has announced that Medicare will pay $10.10 for the influenza vaccine product and $23.28 for the pneumococcal vaccine product.

Physicians should use CPT 90658 to bill the influenza vaccine to Medicare and CPT 90732 to bill for the pneumococcal vaccine. Physicians who administer both must take assignment on the claim for the vaccines. Annual Part B deductible and coinsurance amounts do not apply.

More information on immunization payment rates is on the CMS Web site.

For information about billing and coding for immunizations from ACP's Practice Management Center, go online.

For up-to-date guidance on the flu vaccine shortage, visit ACP's Adult Initiative Web site.

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